AS A HOMECARE PATIENT YOU HAVE THE FOLLOWING RIGHTS
- To decide who provides your home care service and/or equipment.
- To be given legitimate identification of any Provider personnel entering your home to provide homecare services and/or equipment.
- To receive the correctly prescribed service and/or equipment in a professional manner without discrimination of age, race, sex, religion, ethnic origin, sexual preference or physical or mental handicap.
- To be promptly informed if the prescribed care or services are not within the scope, mission, or philosophy of Provider, and therefore are provided with transfer assistance to an appropriate care or service organization.
- To be treated with kindness, courtesy, respect, and without neglect or abuse, either physically or mentally.
- To have your privacy and your property respected at all times.
- To be provided with adequate information to give your informed consent for the start of service, the continuation of service, the transfer of service to another home care provider, or the termination of service.
- To receive upon request, complete and up to date information relative to your condition, treatment, alternative treatments, and risks of treatment within our responsibilities of medical disclosure.
- To receive treatment and services within the scope of your health care plan, promptly and professionally, while being thoroughly informed as to Provider policies, procedures and charges.
- To refuse care, within the boundaries set by law, and receive professional information relative to the ramifications or consequences that will or may result due to such refusal.
- To request and receive data regarding services or costs thereof privately and with confidentiality.
- To request and receive the opportunity to examine or review your medical records.
- To formulate and have honored by all health care Staff an advance directive such as a Living Will or a Durable Power of Attorney for Health Care, or a Do Not Resuscitate order.
- To be involved, as appropriate, in discussions and resolutions of conflicts and ethical issues related to your care.
- To be informed of any experimental or investigational studies that are involved in your care and be provided the right to refuse any such activity.
- To expect that all information received by this organization will be kept confidential and will not be released without written consent.
- To have the right to access, request amendment to, and receive an accounting of disclosures regarding health information as permitted under applicable law.
AS A HOMECARE PATIENT YOU HAVE THE FOLLOWING RESPONSIBILITIES
- To provide complete and accurate information about your present health, medication, allergies, etc., when appropriate to your home care service plan.
- To inform a staff member, as appropriate, of your health history, including past illnesses and injuries, etc.
- To involve yourself in developing, modifying and complying with all aspects of your home care service plan, which includes properly caring for, cleaning and storing of your home medical equipment.
- To review the equipment manufacturers safety procedures and actively participate in maintaining a safe environment in your home.
- To request additional assistance or information on any phase of your home care service plan you do not fully understand.
- To notify your caregiver when you feel ill, or encounter any unusual physical or mental stress or sensations.
- To notify Provider, in advance, when you cannot be home for a scheduled home care visit.
- To notify Provider when changing your place of residence or your telephone number.
- To notify Provider when encountering any problem with equipment or service.
- To notify Provider if your caregiver modifies or ceases your home care prescription.
Delivery and setup of equipment
- Primary delivery method of our equipment is through our partner Clinics and Doctors Offices for the benefit of continuity of care.
- Neb Doctors of Maryland, LLC agrees to deliver any equipment or product that it sells on a timely basis.
- Regularly stocked supplies are usually delivered within 24 hours from the time the order is placed.
- Special orders are usually delivered within 1 week from date of purchase.
- Equipment that Neb Doctors of Maryland, LLC sells will be setup in a timely manner and free of charge.
- Instructions on how to use and maintain the product will be given to each patient accordingly.
Hours of Operation
- Neb Doctors of Maryland, LLC maintains normal business office hours with after hours emergency service availability.
- Neb Doctors of Maryland, LLC is open for business
Monday through Friday 9:00 A.M. to 5:00 P.M.
The office is closed on weekends and holidays (arrangements can be made by appointment only).
- Neb Doctors of Maryland, LLC maintains emergency, on call service for any calls outside of normal business hours.
- The caller may be instructed to leave a message and the person on call will return the call as appropriate.
- The company’s on call number is (410) 335-6175 or 866-643-4020.
Emergency or Natural Disaster
- If you are in need of emergency medical treatment during a natural disaster or other medical emergency contact 911
- If you are in need of services or information for the maintenance, or replacement of medical equipment contact our office number (410) 335-6175 during business hours and our emergency number (410) 335- 6175 outside of those hours.
- If you have a complaint about the service of personnel at Neb Doctors of Maryland, LLC then please call us at (410) 335-6175 to formally file your complaint so that we can answer your concerns and continually improve our service.
- You may also file a complaint to outside sources such as your insurance company, Medicare (800-633-4227) or JCAHO (800-994-6610) email firstname.lastname@example.org.
- Every product sold or rented by our company carries at least a 1-year manufacturer’s warranty. Specific warranty length and information is described in the manufacturer’s owners manual provided with each product.
- Neb Doctors of Maryland, LLC will repair or replace, free of charge, equipment that is under warranty. In addition, an owner’s manual with warranty information will be provided to beneficiaries for all durable medical equipment where this manual is available.
Statement to Permit Payment of Medical Benefits
- I understand that I am authorizing Neb Doctors of Maryland, LLC to provide Medical Equipment and/or services to me.
- I understand that I am giving Neb Doctors of Maryland, LLC permission to ask my insurance for payments for my medical care, including supplies and equipment.
- I certify that the information provided by me in applying for payment under title XVIII (Medicare) of the Social Security Act or any other insurance benefits is true and correct.
- I understand that Health Care Benefit Payee may need information about my medical condition to determine benefits related to “Company” services. I give permission for the release of medical or other information necessary to process the “Company” payment request.
- I ask that payment of authorized Health Care Benefits be made on my behalf to Neb Doctors of Maryland, LLC for any services or items furnished to me.
- I understand that if my insurance denies or challenges this claim for the prescribed supplies, I will be solely responsible for this claim
Client Responsibility Waiver
- Medicaid, Medicare or any other health insurance company will only pay for equipment and services that it determines to be “reasonable and necessary” (Section 1862(a)(l) of the Medicare law for Medicare). If your insurance determines that a particular service or piece of equipment is not “reasonable and necessary” under your insurance standards, your insurance company may deny payment for it. In the event that they do deny payment, you will be responsible for the reasonable and customary cost of the equipment or service.
- I certify that I HAVE NOT RENTED SAME OR SIMILAR EQUIPMENT through Medicaid, Medicare or any other insurance, or If SAME OR SIMILAR equipment was rented, the equipment has since been returned to the DME supplier. I also certify that Medicare is not paying service or maintenance charges for SAME OR SIMILAR equipment I use.
- I certify that I HAVE NOT PURCHASED SAME OR SIMILAR equipment through Medicare, Medicaid or any other Insurance, or if I have purchased any equipment, documentation has been provided to Neb Doctors of Maryland, LLC.
- I understand that most insurance will only cover one nebulizer every three years, and I understand that if my insurance denies or challenges this claim for SAME OR SIMILAR equipment being rented or purchased, I will be solely responsible for this claim.
- If my insurance should deny payment for any reason other than the above stated reason, I will be solely responsible for this claim.
- I will cover any and all additional charges involved in having the equipment returned.
- Neb Doctors of Maryland, LLC reserves the right to have this agreement transferred over to another Medicare Supply or Pharmacy provider to provide the service.
Deductibles and Co-insurance
- I understand that any annual deductible or co-payments from my insurance are my responsibility unless covered by a secondary insurance policy.
A representative of Neb Doctors of Maryland, LLC or my doctor’s office has advised me of the following:
- The proper and safe operation of the unit
- Basic maintenance of the unit
- That I must read and fully understand the owner’s manual that I have received before operating the unit
To our patients: This notice describes how health information about you, as a patient of Neb Doctors of Maryland, LLC, may be used and disclosed. You will also find below, information on your rights and how you can get access to your health information. This is required by the Privacy Regulations created as a result of the Health Insurance Portability and Accountability Act of 1996 (HIPAA).
Our commitment to your privacy
Neb Doctors of Maryland, LLC is dedicated to maintaining the privacy of your health information. We are required by law to maintain the confidentiality of your health information. We realize that these laws are complicated, but we must provide you with the following important information:
Use and disclosure of your health information in certain special circumstances
The following circumstances may require us to use or disclose your health information:
- In the process of providing you services and in the claims submission to other Healthcare organization for reimbursement.
- To public health authorities and health oversight agencies that are authorized by law to collect information.
- Lawsuits and similar proceedings in response to a court or administrative order.
- If required to do so by a law enforcement official.
- When necessary to reduce or prevent a serious threat to your health and safety or the health and safety of another individual or the public. We will only make disclosures to a person or organization able to help prevent the threat.
- If you are a member of U.S. or foreign military forces (including veterans) and if required by the appropriate authorities. To federal officials for intelligence and national security activities authorized by law.
- To correctional institutions or law enforcement officials if you are an inmate or under the custody of a law enforcement official.
- For Workers Compensation and similar programs.
Your rights regarding your health information
- Communications. You can request that Neb Doctors of Maryland, LLC communicate with you about your health and related issues in a particular manner or at a certain location. For instance, you may ask that we contact you at home, rather than work. We will accommodate reasonable requests.
- You can request a restriction in our use or disclosure of your health information for treatment, payment, or Healthcare operations. Additionally, you have the right to request that we restrict our disclosure of your health information to only certain individuals involved in your care or the payment for your care, such as family members and friends. We are not required to agree to your request; however, if we do agree, we are bound by our agreement except when otherwise required by law, in emergencies, or when the information is necessary to treat you.
- You have the right to inspect and obtain a copy of the health information that may be used to make decisions about you, including patient Medical records and billing records, but not including psychotherapy notes. You must submit your request in writing to: (See Neb Doctors of Maryland, LLC Information Below)
- You may ask us to amend your health information if you believe it is incorrect or incomplete, and as long as the information is kept by or for our practice. To request an amendment, your request must be made in writing and submitted to: (See Neb Doctors of Maryland, LLC Information Below) you must provide us with a reason that supports your request for amendment.
- Right to a copy of this notice. You are entitled to receive a copy of this Notice of Privacy Practices.
- You may ask us to give you a copy of this Notice at any time. To obtain a copy of this notice, contact: (See Neb Doctors of Maryland, LLC Information Below).
- Right to file a complaint. If you believe your privacy rights have been violated, you may file a complaint with our practice or with the Secretary of the Department of Health and Human Services. To file a complaint with our practice, contact: (See Neb Doctors of Maryland, LLC Information Below) All complaints must be submitted in writing. You will not be penalized for filing a complaint.
- Right to provide an authorization for other uses and disclosures. Our practice will obtain your written authorization for uses and disclosures that are not identified by this notice or permitted by applicable law.
If you have any questions regarding this notice or our health information privacy policies, please contact Neb Doctors of Maryland, LLC